Ramblings of an Emergency Physician in Texas

Where are the Physician Leaders?

I received a thoughtful email the other day, and though I only have partial answers, I wanted to share it and give my response.

I follow health care issues in the newspaper and on radio. I am as far from understanding the complexities of medicine and patient care as Pluto is from Mars. But, I often ask myself the question, where are the docs? The issues concerning health care: rising costs and the uninsured, sharpen with each day. Can the medical community organize among themselves and take a leadership role in implementing solutions for these issues? Can physicians be more than influential advocates? Can the medical community take the initiative to develop a health care system that is responsive to all, regardless of financial circumstances? By applying their culture of excellence, they can be valued by all who seek relief, not only by those who can afford it.

This is a good (series of) questions, and one I’m not terrifically well equipped to answer, as my role in medicine is in the practice and not the administration of medicine. However, I’ll give my grunts’-eye view.

Can the medical community organize themselves and take a leadership role? Well, probably not, but for several reasons. Some of that has to do with the analogy that getting more than three docs to agree on a policy is like herding cats, but also with the realization that there isn’t any one, or even series of answers to the major questions of reimbursement or access that a majority of docs agree on. Single Payor has its proponents, and they make impassioned arguments. Those opposed to a single payor system (and I’m one of them) are not willing to take the chance that the unknown devil is better then the one we have, and there’s not much middle ground there.

Can physicians be more than influential advocates? Not unless there’s a considerable shift in the focus of an awful lot of physicians who decide to embark on a career in politics. The solution to health care and costs isn’t in the hospital, or the state medical society, or with the AMA, though all are active in their respective legislative domains.

Ultimately, the ‘answers’ are political ones, they aren’t easy, and they aren’t made exclusively or even largely by docs. They’re going to be made by politicians, and ultimately by the voters (our patients).

Comments

One of the problems (out of many) that we docs have is that our point of view is felt to be tainted.
The “rules” of healthcare are set mainly by the payors, ie, the government and insurance companies.

What I would mainly like to see is a level playing field in as many areas as possible, so that I have a single fee for each service I perform, regardless of the type or even presence of health insurance. This would greatly simplify the billing process.

Furthermore, the price for health insurance should be the same for everyone — a company could refuse to sell insurance to someone, but if they offered it, it should be no more expensive than someone at Ford or GM pays.
It’s hard to know what to do about universal health care. There are many now who could afford to buy insurance but choose not to. When they get significantly ill, it’s a catastrophe, but they’re willing to take the chance. Doctors are the ones least likely to get paid in these situations.

There’s a substantial money-grab going on. It seems everyone (hospitals, private companies, doctors) wants to open their own MRI scanning facility where I am. I would prefer to see someone tackle the cost of an MRI (it’s really outrageous) rather than simply trying to profit from it.

The health care problem will not be solved until someone (as you said, it needs to be a politician) is willing to give voice to the central question that everyone dances around….how will we ration healthcare. Every country in the world rations it (to avoid bankrupting the treasury)but no one puts it in those terms. Unfortunately, saying this guarantees one’s opponent election.

In the US, we ration it with dollars, in Britain it’s done with time. Canada seems to be some hybrid of these. The Nordic countries tried to do no rationing and are now backing off since tax rates cannot excede 100% of income.

This gets into value judgements of whose life is worth more. Is it the wealthy – I’ve got problems with that, but philosophically Bill Gates feeds about 180,000 more people (through employment) than I do so maybe we should keep him healthy before treating me. Is it the young – I imagine the AARP has an opinion on that. Is it the old – they consume most of the health care dollars, but then they created the industries generating those dollars in the first place. I really don’t have an answer, I’m just putting possibilites out for discussion.

MDs are not in a position to lead this discussion since it contravenes both their education and the reason they became MDs in the first place. Actually giving voice to the idea of rationing health care says clearly that those at the bottom of the que (whatever the criteria used) will be left to die from ailments that those at the top of the que will be cured of. MDs are healers, not killers.

These are some of the straightest and most intelligent comments I’ve seen in a long time on a staggeringly complex problem. No system is going to work perfectly, but some do certainly work better than others (according, of course, to the parameters you plug in to define “better”). The existing non-system in the United States does a few things well and a lot horribly — arguably much worse in terms of promoting the general welfare and longevity of the greatest number than the flawed approaches taken by most other industrialized countries. But Gruntdoc, Greg P and Jim K have it right — physicians themselves will not be the saviors who untangle the mess for us, for the reasons they clearly articulate. It’s refreshing if not soothing to hear challenging realism (which allows for imperfect lurches in the direction of solutions) and not glib certainty when it comes to this issue.